GW1-2021-05853_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: e
John W. Huneycutt FR.WATER ZONES
it FROM TO DESCRIPTION
Well Contractor Name 130 fit• 140 ft- 10 gpm
2465-A �UL 2021 250 ft- 260 ft• 30 gpm
NC Well Contractor Certification Number OURER CASING for mDlli psed wells OR LINER if a livable
pic�ess+n9 FAOM TO DIAMETER 17R[7avFcc nIATERIAI
Derry's Well Drilling, Inc. �nfaccratlo� �edlO11 0 tt. 55 fit 6 1/8 ! i'" 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TURtNG eothermal closed-loop)
Parcel# 1033 (Well #3) FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft. In.
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. is
OAgricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 fit' 3 R- Bent.Chips Gravity
Non-Water Supply Well;
3 ft. 35 ft- Bentonite Pumped
❑Monitoring ❑Recovery
injection Well:
fit. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,Wit 'n sine,etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 14 ft Red Clay
4.Date Well(s)Completed: 3/23/21 Well TIM 3 14 ff 33 ft. Brown Dirt
33 fit 500 ft• Slate
5a.Well Location: ft. ft.
Jerry Hudson ft. rr
Facility/Owner Name Facility M#(if applicable)
ft. fit Seams:65', 105', 130'=109pm, 198',
2623 Silk Hope Rd, Siler City 27344 n. ft. 215',250'=30gpm
Physical Address,City_and Zip
21.REMARKS.
Chatham 1033
County Parcel Identification No.(PITS
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) 9��&
N W �GtIL4,� 4/1/21
Si64turc of Certified Well ContractoiV Date
6.Is(are)the well(s): 551'ermanent or ❑Temporary Ay signing this form,1 hereby certify that the well(k)was(were)constructed in accordance
with 15A N(:AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of this retard has been provided to the well oirner.
If this is a repair,fill out knrnvn well construction information and explain the nature of the
repair under r 21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
.submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- 265 (rt•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifili ferem(example-3@200'and 2 n 100') constmction to Ute following:
10.Static water level below top of casing: 27 (ft.) Division of Water Resources,Information Processing Unit,
Ifrvaierlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Welts ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy oftfhis form,within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: Air
24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Amount: 1/2 lb. well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department ofEnvironment and Natural Resources—Division of Water R�ourom Revised August 2013
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